mercredi 2 août 2017

The opioid epidemic

I'm starting this thread on a huge topic because it keeps getting brought up in the painful process of passing a hopefully halfway decent health-care bill.

Here is my main question, and it's medical, not political: If billions are dedicated solely to treatment for opioid dependency, what does the solution look like?

The last Senate iteration provided those billions, but then slashed Medicaid, which providers said would make it much harder for addicts to get appropriate treatment.

This NBC story gets into some of the nitty-gritty, and there are plenty of other links I could provide, but almost any comprehensive media report can provide the basic of the issue. What I want to know what the infrastructure of this care would look like, and what ideological battles might have to be fought. Statistics for recovery from opioid dependency aren't great for full-blown addicts. Some studies indicate a 91 percent relapse rate. People who got into using for relief of physical pain can be detoxed fairly straightforwardly, but the problem is much tougher when people are using opioids to treat emotional pain such as depression over job loss and general hopelessness. For some the best option might be lifelong maintenance with methadone or Suboxone. Methadone is a problem because it can be diverted, and because huge tolerances encourage higher doses which become dangerous as take-home doses get diverted, as some will. Suboxone is safer, and effectively blocks the effect of stronger opioids, but there are issues. You must already be in withdrawal before it is safe to give Suboxone. And quite frankly, IMO, its effects are not as euphoric as other opioids, including methadone, which is also cheaper. It can, though, provide other advantages that make up for the loss of euphoria.

If we had triage for opioid addicts, what would that look like? People being detoxed with the old 30-day inpatient stay? People on outpatient counseling and replacement therapy? People directed to faith-based abstinence programs, which do actually work for some? Those are very cheap, actually free for the most part, but they're not for everyone. All IMO would need a strong emphasis on relapse prevention, a lot of education and possibly support groups.

We've had this perfect storm of cheap heroin, opportunistic marketing of OxyContin, which once had a 160 mg pill - that is the equivalent of *32* Percocet - which killed quite a few people because crushed up and snorted, that would be a lethal dose for quite a few people. Adulteration with fentanyl and carfentanil has caused many deaths. You can die just handling carfentanil. IMO another problem is that widespread use of hydrocodone, which became a substitute for codeine, turned out to be more addictive than codeine and was upgraded to Schedule II status, probably belatedly.

This is such a complex and seemingly intractable problem that I'm wondering how effective even top-notch medical care is when the continued temptation of chemical relief is easily fulfilled and can put addicts back at square one in a hurry.

Should treatment aim at abstinence or harm reduction, two philosophies that can sometimes clash? I just don't know and am interested in hearing other people's thoughts. I've even wondered if things will just dissipate on its own, as the human cost of addiction becomes glaring enough. Not too confident on that last bit.